CAASTROKE: FAQs on CAA from http://www.angiopathy.org

COMMUNITYHEALTH: Federally qualified health centers

DRIVINGEVAL: PA and NJ rehabs doing driving evals

SPEECHTHERAPY: area speech pathologists

NEUROREHAB: PA and NJ major rehabs

THERAPY: how to find a local mental health therapist ; national resources

RZBBEHAVRESOURCES: Community behavioral health clinics, crisis response, substance use, LGBTQ

MOODCHANGESAFTERSTROKE: what to expect

YUANFINDDIETICIAN: http://www.eatright.organd other resources

YUANMEDALERT: how to get medical alert devices

PTINFOSZSAFETY: seizure safety tips

PVINSTFUNCTIONAL: psych/therapy resources for FND

STROKESUPPORTGROUP: Penn monthly virtual support group

STROKEWORKUPNUMBERS: phone numbers for echo, NV lab, Penn labs, rads, etc

LOWVISION: Area low vision services for retinal/optic nerve issues, not VF defects

OPSTROKETRIALS:  reminder of Penn stroke trials relevant to outptsetting]

BCNEUROGENETICS: information for patients on neurogenetics consult/testing

Data:

.hypercoagnormal

Protein C, protein S, antithrombin III, factor V Leiden, prothrombin gene G20210A, and antiphospholipid antibodies were all normal.

Plan:

.cadasil

(cerebral autosomal dominant arteriopathy with subcortical infarctions and leukencephalopathy)

.kasnercaa

…cerebral amyloid angiopathy (CAA). Unfortunately, there is currently no specific therapy for CAA.  It is an age-related disorder in which amyloid deposition in the cerebral blood vessels predisposes them to hemorrhage.  The patient should avoid antithrombotic medications and should scrupulously control the BP.  Despite these interventions, there is a relatively high risk for recurrent ICH.  A clinical trial of an anti-amyloid therapy is being planned and perhaps that could be considered when it is open for enrollment.

.kasneresus

                … presents with an embolic-appearing ischemic stroke of undetermined source (ESUS). We discussed results of testing at length. Despite an extensive evaluation, we were unable to identify any specific cause. At this point, the common approach is to treat with antiplatelet therapy and risk factor modification, as recent research has not supported anticoagulation. However, there are some exceptions…

.kasnerpfo

A patent foramen ovale (PFO) was identified and could be a potential source of thromboembolism.  For many years, the relationship between stroke and PFO seemed complicated and uncertain, but recent studies have helped clarify the situation.  At present, the PASCAL tool helps to identify patients whose stroke is probably, possibly, or unlikely related to the PFO.  Those with probable PFO-associated stroke benefit the most from closure (~90% reduction in risk) and have the lowest risk of AF as a complication of the procedure.  Those with possible classification also clearly benefit from closure, though to a somewhat lesser degree (~60% risk reduction).  Those whose stroke is unlikely PFO-associated do not benefit from closure and have the highest rate of post-closure AF.  This patient falls into the *** category and therefore I recommend ***.

We had an extremely extensive discussion about PFO and the risks and benefits of these possible treatment strategies and the patient understands the current situation. The patient should see our colleagues in cardiology to discuss next steps.

I advised the patient to avoid dehydration and be cautious about prolonged immobilization, such as may occur during travel and other situations, and encourage them to drink fluids and ambulate as much as possible when travel is needed.  I also advised the patient not to SCUBA dive.

Other:

.kasnerclearance

The above named patient is being considered for an invasive procedure or surgery in the near future.  There are no formal or standard approaches to “neurological clearance” prior to such procedures.  In general, the risk of stroke with non-cardiovascular procedures and surgeries is low. 

However, there is a measurable increase in the risk of stroke if antithrombotic therapy is discontinued for the procedure.  We recommend that antithrombotic therapy not be interrupted if possible, or that the interruption be as short as possible if it is required. 

The optimal blood pressure during invasive procedures is debatable, but it appears that BP reductions of more than 20 mm Hg or 20% below preoperative levels may increase the risk of perioperative stroke.

Early mobilization is also recommended.

Please feel free to contact me if you have any questions or concerns.